How does organisational context impact on antibiotic stewardship in primary care?

Reducing antibiotic use in healthcare is critical in managing the growing problem of antimicrobial resistance. We aimed to explore the impact of organisational context on how antibiotic stewardship is enacted in primary care, in order to inform the development and implementation of novel interventions. Ethnographic observations were conducted in four primary care practices in England (two high antibiotic prescribers, and two low), drawing on Bate et al’s (2008) model of six universal challenges for organising quality in
healthcare. Here we focus on structural and cultural/social challenges. We identified that availability of access to appointments, prescriber confidence in patient safety netting (patients re-consulting in the case of symptom deterioration), and patient usage of alternative services, all contributed to shaping practices around antibiotic use. Our findings suggest that having better structures in place to deal with high demand and return appointments, including in-house quick access clinics and walk-in services, facilitated efforts to optimise antibiotic use. Characteristics of the patient population, including transience and vulnerability, impacted on prescribers’ confidence in using a safety netting approach. Stewardship efforts were compromised in practices in which accessibility was lower, and when patients relied more heavily on alternative out of hours or emergency services. Inconsistencies in prescribing